Preeclampsia Top of Form Initial History and Assessment

Jennie arrives at the Labor and Delivery triage area at 0600 with her sister. She has been experiencing a severe headache for the past 12 hours, which has not been relieved by acetaminophen (Tylenol). Additionally, she has noticed swelling in her hands and face over the last 2 days and describes her epigastric pain as similar to bad heartburn. Jennie’s sister informs the nurse that she had similar symptoms during her own pregnancy, which turned out to be toxemia.

The nurse’s admission assessment reveals that Jennie weighs 182 pounds today. Her body temperature is recorded as 99.1° F, pulse rate is 76, respiration rate is 22, and blood pressure is measured at 138/88. There is noticeable pitting edema graded at +4 and urine analysis shows protein levels of +3. Jennie’s heart rate is regular and lung sounds are clear.

The nurse assesses the deep tendon reflexes (DTRs) and finds them to be 3+ in the biceps and triceps muscles, and 4+ in the patellar reflex with 1 beat of ankle clonus. Additionally, the nurse applies an external fetal monitor and observes a baseline fetal heart rate of 130 bpm, absent variability, positive for accelerations, no decelerations, and no contractions. Furthermore, a vaginal examination is performed by the nurse and reveals a cervix that is 1 cm dilated and 50% effaced, with the fetal head positioned at a -2 station.

1. The nurse believes that based on Jennie’s history, she is at risk of developing a hypertensive disorder. What are the specific risk factors contributing to this conclusion?

1. Age (15), molar pregnancy, history of preeclampsia in a previous pregnancy.
2. Age (15), gravidity, familial history.
3. Age (15), history of pounding headache, low socioeconomic status.
4. Age (15), low socioeconomic status (SES), history of pedal edema.

2. The nurse should obtain the most important information from the prenatal record in order to accurately assess the client’s condition.

1. Pattern and number of prenatal visits.
2. Prenatal blood pressure readings.
3. Prepregnancy weight.
4. Jennie’s Rh factor.

Assessing Deep Tendon Reflexes

Purpose

In order to evaluate hyperreflexia or hyporeflexia, use a reflex hammer to assess the brachial and patellar reflexes. When examining the brachial reflex, hold the woman’s arm and request that she fully relax it while keeping it slightly flexed. If you have difficulty finding the correct tendon to tap, ask her to flex and extend her arm until you can feel it moving under your thumb.

After identifying the tendon, instruct the woman to completely relax her arm. Position your thumb on the tendon as illustrated, enabling both visual and tactile feedback when tapping it. Utilize the smaller end of the triangular reflex hammer to strike the thumb. A typical response will cause a slight flexion in the forearm. To evaluate the patellar reflex (also referred to as knee-jerk reflex), you may either have the woman sit or lie down. If she is sitting, let her lower legs hang freely to flex the knee and stretch the tendons.

If locating the patellar tendon proves difficult, one can instruct the woman to slightly flex and extend her lower legs until the tendon becomes palpable. To assess the patellar reflex, strike the tendon with a reflex hammer just below the patella. It is important to note that if the woman has received epidural analgesia, this may affect the reliability of the patellar reflex; therefore, upper extremity reflexes should also be evaluated. When positioning the woman in a supine position, it is crucial to provide support for her leg’s weight to facilitate flexion and extension of the knee tendons. For an accurate response, ensure that limb is relaxed and partially stretched prior to striking it just below the patella.

The expected response is a slight extension of the leg or a brief twitch of the quadriceps muscle of the thigh. To assess clonus, support the lower leg and dorsiflex the footwell to stretch the tendon. Hold the flexion. If no clonus is present, no movement will be felt. Clonus, indicating hyperreflexia, is characterized by rapid rhythmic tapping motions of the foot.

The Deep Tendon Reflex Rating Scale: 0 indicates absent reflex, +1 indicates reflex present but hypoactive, +2 indicates normal reflex, +3 indicates brisker than average reflex, and 4 indicates hyperactive reflex with possible clonus present. Some facilities may exclude plus signs from their rating scales.

Pathophysiology of Preeclampsia

Preeclampsia is a condition where arterioles become narrower, leading to inadequate blood flow to important organs like the placenta, liver, brain, and kidneys. As a result, these organs may only operate at 40 to 60% of their normal capacity. Furthermore, there is a decrease in plasma volume and an increase in hematocrit as fluid exits the blood vessels.

Preeclampsia is a condition that leads to extensive edema, impacting nearly all organs in the body. As the illness advances, both the mother and fetus become more vulnerable. It usually occurs in women who previously had normal blood pressure after 20 weeks of pregnancy. Elevated blood pressure is frequently the initial indication of preeclampsia. The client also experiences proteinuria. Although it is no longer deemed a conclusive marker of preeclampsia, general swelling of the face, hands, and abdomen that persists even after 12 hours of bed rest is often observed.

Preeclampsia can advance from mild to severe stages, including HELLP syndrome or eclampsia. A client can arrive at the labor unit at any point along this progression.

What is causing Jennie to experience a pounding headache and elevated deep tendon reflexes?

1. Cerebral edema.
2. Increased perfusion to the brain.
3. Severe anxiety.
4. Retinal arteriolar spasms. Jennie’s sister is very concerned about the swelling (edema) in her sister’s face and hands because it seems to be worsening rapidly.

She inquires with the nurse about the possibility of the healthcare provider prescribing diuretics, also known as “water pills,” to help eliminate the surplus fluid.

4. What is the correct response by the nurse?

1. “That is a very good idea. I will relay it to the healthcare provider when I call. “
2. “I’m sorry, but it is not the family’s place to make suggestions about medical treatment. “
3. “Let me explain to you about the effect of diuretics on pregnancy. “
4. “Have you by any chance given your sister water pills that belong to someone else? “

At 0630, the nurse contacts the healthcare provider to report the admission to the Labor and Delivery Unit. The healthcare provider then prescribes several actions including admitting the patient to labor and delivery, bedrest with bathroom privileges (BRP), intravenous infusion of D5LR at 125 ml/hr, a complete blood count (CBC) with platelets, clotting studies, liver enzymes, a chemistry panel, a 24-hour urine collection for protein and uric acid, intake of only ice chips by mouth, nonstress test, hourly monitoring of vital signs, and testing of deep tendon reflexes (DTRs).

5. What is the highest priority nursing intervention while waiting for the lab results?

1. Teach Jennie the rationale for bedrest.
2. Monitor Jennie for signs of dehydration.
3. Educate the client about dietary restrictions.
4. Observe Jennie for CNS changes.

6. What is the most effective technique for the nurse to assess Jennie’s blood pressure while she is on bedrest?

1. Have Jennie lay supine and take the blood pressure on the left arm.
2. Have Jennie lie in a lateral position and take the blood pressure on the dependent arm.
3. Have the client sit in a chair at the bedside, and take the blood pressure with her left arm at waist level.
4. Have Jennie stand briefly and take the blood pressure on the right arm. The nurse performs a nonstress test to evaluate fetal well-being.

7. The nurse will assess which parameters when performing a nonstress test?

1. Accelerations of the fetal heart rate in response to fetal movement.
2. Late decelerations of the fetal heart rate in response to fetal movement.
3. Accelerations of the fetal heart rate in response to uterine contractions.
4. Late decelerations of the fetal heart rate in response to uterine contractions.

At 0800, the client presents with symptoms indicative of HELLP syndrome. These symptoms include a headache and slightly reduced epigastric pain. During a physical assessment, the vital signs are measured at BP 146/94, P 75, R 18 while the client is in a left lateral position. Hyperreflexia is still present along with one beat of clonus. The fetal heart rate is recorded as 140 with average long-term variability and no decelerations following a reactive nonstress test. However, there have been no further accelerations since then. Lab results show hemoglobin levels at 13.1 g/dl, hematocrit levels at 40 g/dl, platelet count at 120,000 mm3 which is slightly elevated aspartate aminotransferase (AST), normal levels of alanine aminotransferase (ALT) for pregnancy, and no burr cells on slide. Clotting studies also indicate normalcy for pregnancy.

Based on these findings, the healthcare provider diagnoses Jennie with preeclampsia rather than HELLP syndrome which is known to be a severe variant of preeclampsia.

8. The nurse would expect Jennie to exhibit specific lab results if she had HELLP syndrome.

1. Elevated hemoglobin and hematocrit (H&H) without burr cells, elevated liver enzymes, platelet count >150,000 mm3.
2. Decreased hemoglobin and hematocrit (H&H) with burr cells, elevated liver enzymes, platelet count